GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Towards universal access for women, infants and young children and eliminating HIV and AIDS among children with The Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children

WHO Library Cataloguing-in-Publication Data: Guidance on global scale-up of the prevention of mother to child transmission of HIV: towards universal access for women, infants and young children and eliminating HIV and AIDS among children / Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. 1.HIV infections prevention and control 2. Acquired immunodeficiency syndrome prevention and control. 3.HIV infections in infancy and childhood. 4.Disease transmission, Vertical prevention and control. 5.Maternal health services. 6.Health services accessibility.7.international cooperation. I.Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. ISBN 978 92 4 159601 5 (NLM classification: WC 503.2) World Health Organization 2007 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Towards universal access for women, infants and young children and eliminating HIV and AIDS among children The Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children

INTERAGENCY TASK TEAM ON PREVENTION OF HIV INFECTION IN PREGNANT WOMEN, MOTHERS AND THEIR CHILDREN The Interagency Task Team (IATT) on the Prevention of Mother-to-Child Transmission of HIV was established in 1998 following initial reports of the results of the effi cacy of short course antiretroviral drug regimens in preventing transmission from infected women to their infants. In 2001, the Interagency Task Team was renamed the Interagency Task Team on Prevention of HIV Transmission in Pregnant Women, Mothers and their Children. The IATT includes the World Health Organization (WHO), the United Nations Children s Fund (UNICEF), the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS) Secretariat, the World Bank (WB), the United States Centers for Disease Control and Prevention (CDC) and the United States Agency for International Development (USAID), the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), as well as prominent international nongovernmental organizations such as the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), the International Center for AIDS Care and Treatment Programs at Columbia University s Mailman School of Public Health, Family Health International (FHI), the Clinton Foundation HIV/AIDS Initiative (CHAI), Catholic Medical Mission Board (CMMB), the Academy for Educational Development (AED), Population Council, the International Center for Reproductive Health (ICRH), and Ensemble pour une Solidarité Thérapeutique Hospitalière en Réseau (ESTHER). The original purpose of the IATT was to contribute to improving and scaling up programmes to prevent HIV infection in pregnant women, mothers and their children, in accordance with the Declaration of Commitment on HIV/AIDS of the United Nations General Assembly Special Session on HIV/AIDS in 2001. This goal was expanded in 2003 when the United Nations adopted a comprehensive strategic approach to the prevention of HIV infection in infants and young children which includes the following four components: 1. primary prevention of HIV infection among women of childbearing age; 2. preventing unintended pregnancies among women living with HIV; 3. preventing HIV transmission from a woman living with HIV to her infant; and 4. providing appropriate treatment, care and support to mothers living with HIV and their children and families. In 2006, the IATT decided to expand its focus to include HIV care and treatment for children. The purpose of the IATT simultaneously expanded to address improving and scaling up HIV care and treatment for children, including early diagnosis, expanded treatment access and increased integration of HIV care and treatment for children. The IATT also aims to strengthen partnerships that address the broader health concerns and survival of women, infants and children within the context of HIV. Within the framework of their respective mandates, comparative advantages, capacity and technical expertise, the IATT partners are committed to addressing issues related to policies, strategies, mobilizing and allocating resources, providing technical assistance to governments for accelerating the scaling up of programmes, and tracking the global progress of the prevention of mother-to-child transmission of HIV and HIV care and treatment for children. 2 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

TABLE OF CONTENTS EXECUTIVE SUMMARY... 5 I. BACKGROUND... 7 1. HIV in women and children... 7 2. Global commitments... 8 3. Status of implementation of PMTCT programmes... 9 II. PURPOSE AND INTENDED AUDIENCE OF THE GUIDANCE... 12 III. GUIDING PRINCIPLES...14 1. Urgent scale-up to achieve national coverage and universal access...14 2. Country ownership and accountability...14 3. Emphasizing the participation of people living with HIV and communities...14 4. Strong, coordinated and sustained partnerships...14 5. Aiming for both impact and equity...14 6. Delivering a comprehensive package of services based on the United Nations four-element strategy, including links between services and integration with maternal, newborn and child health services... 15 7. Giving priority to providing antiretroviral therapy to eligible pregnant women... 15 8. Family-centered longitudinal care... 15 9. Importance of male involvement... 15 10. Improving maternal and child survival... 15 IV. STANDARD OF CARE... 16 V. GOAL AND TARGETS...17 1. Goal...17 2. Impact target for 2010...17 VI. RECOMMENDED PRIORITY STRATEGIES AND ACTIONS AT COUNTRY LEVEL... 19 1. Demonstrated government leadership, commitment and accountability to deliver on the goal of universal access to PMTCT and HIV care for children... 19 2. District-driven delivery of a standard package of comprehensive services... 19 3. Institutionalizing provider-initiated HIV testing and counselling in maternal, newborn and child health settings... 20 4. Institutionalizing longitudinal HIV care management in maternal, newborn and child health settings... 20 5. Increasing access to antiretroviral therapy for pregnant women, mothers and their children and families in the context of PMTCT... 21 6. Strengthening infant feeding and nutrition advice, counselling and support for women and their children and families in the context of PMTCT and HIV care for children... 21 7. Operationalizing the link between the delivery of PMTCT and of sexual and reproductive health services... 21 8. Empowering and linking with communities... 22 3

VII. ROLES OF PARTNERS... 24 1. Concerted response by partners at the country level to maximize their support to national governments... 24 a. Advocacy, partnership development and planning support... 25 b. Mobilizing and allocating resources... 25 c. Technical assistance to support and guide country-level implementation... 25 2. Setting the global agenda for PMTCT and HIV care for children and maintaining momentum... 26 a. Mobilizing the international community, galvanizing political will and mobilizing resources for an HIV-free and AIDS-free generation... 26 b. Develop evidence-based policies, guidelines and programming tools to support country-level implementation... 26 c. Support regional and national planning and capacity-building for the delivery of PMTCT and HIV care for children within maternal, newborn and child health services... 27 d. Support evidence-based strategic information to track progress, improve programming and guide policies...27 e. Support the strengthening of health systems for delivering a standard of care for PMTCT within maternal, newborn and child health services... 27 VIII. CONCLUSION... 28 REFERENCES... 29 ANNEXES... 30 Annex 1. Package of essential services for high-quality maternal care... 30 Annex 2. Essential postnatal care for HIV-exposed infants and young children... 31 Annex 3. Antiretroviral regimens recommende by WHO for treating pregnant women and preventing HIV infection in infants... 31 Annex 4. Key entry points and interventions: primary prevention and prevention of unintended pregnancies among women living with HIV... 32 Annex 5. Key resources... 33 4 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

EXECUTIVE SUMMARY AIDS has become a leading cause of illness and death among women of reproductive age in countries with a high burden of HIV infection. Infants born to women living with HIV can become infected during pregnancy, labour and delivery or postpartum through breastfeeding. More than 1400 children under 15 years of age therefore become infected with HIV every day, most through mother-to-child transmission. Children account for more than 10% of all new HIV infections. In most high-income countries, wide implementation of an evidence-based package of interventions built around the use of antiretroviral drugs, the avoidance of breastfeeding and elective caesarean section has virtually eliminated new HIV infections among children. In contrast, resource-constrained settings have made little progress in scaling up services for the prevention of mother-to-child transmission (PMTCT), and current achievements fall far short of achieving the targets set by the United Nations General Assembly Special Session on HIV/AIDS in 2001. Global coverage of PMTCT services is still low. In 2005, only about 11% of pregnant women living with HIV gained access to HIV testing and counselling and antiretroviral prophylaxis interventions during pregnancy. In addition, most national programmes have paid little attention to primary prevention of HIV in women of childbearing age, preventing unintended pregnancies among women living with HIV and access to antiretroviral therapy for women and children. The current global guidance has been developed in response to this slow, overall progress to scale up PMTCT in resource-constrained settings. It provides a framework for concerted partnerships and guidance to countries on specifi c actions to take to accelerate the scale-up of PMTCT. The implementation of actions recommended by this guidance aims to reinforce some recent encouraging trends in the coverage of national programmes. In 2006, at least eight countries exceeded the 40% antiretroviral prophylaxis uptake mark required to achieve the 2005 PMTCT target of the United Nations General Assembly Special Session on HIV/AIDS. The guiding principles The global guidance supports the implementation of all four components of the United Nations comprehensive approach: primary prevention of HIV among women of childbearing age; preventing unintended pregnancies among women living with HIV; preventing HIV transmission from a women living with HIV to her infant; and providing appropriate treatment, care and support to women living with HIV and their children and their families. It is built around 10 guiding principles for country-level action for scaling up PMTCT: 1. urgent scale-up to achieve national coverage and universal access; 2. country ownership and accountability; 3. emphasizing the participation of people living with HIV and communities; 4. strong, coordinated and sustained partnerships; 5. aiming for both impact and equity; 6. delivering a comprehensive package of services based on the United Nations four-element strategy, including links between services and integration with maternal, newborn and child health services; 7. giving priority to providing antiretroviral therapy for treating eligible pregnant women; 8. family-centred longitudinal care; 9. the importance of male involvement; and 10. improving maternal and child survival. This document promotes the integration of PMTCT and links with maternal, newborn and child health, antiretroviral therapy, family planning and sexually transmitted infection services. The goal of this is to ensure the delivery of a package of essential services for quality maternal, newborn and child care that should includes routine quality antenatal care for all women regardless of HIV status and additional comprehensive services for women living with HIV and care for HIV-exposed infants and young children (Annexes 1 and 2). 5

Strategic approaches In keeping with these guiding principles, the following strategic approaches are proposed: demonstrated government leadership, commitment and accountability to deliver on the goal of universal access to PMTCT and HIV care and treatment for children; district-driven delivery of a standard package of comprehensive services; institutionalizing provider-initiated HIV testing and counselling in maternal, newborn and child health settings; institutionalizing longitudinal HIV care management in maternal, newborn and child health settings and developing strong links to antiretroviral therapy services; increasing access to antiretroviral therapy for pregnant women, mothers and their children and families in the context of PMTCT; strengthening infant feeding and nutrition advice, counselling and support for women, their children and families in the context of PMTCT and HIV care and treatment for children; operationalizing the link between the delivery of PMTCT and sexual and reproductive health care; and empowering and linking with communities. Partner commitment The partners endorsing this global guidance document commit themselves to revitalizing the global PMTCT agenda by: mobilizing the international community, galvanizing political will and mobilizing resources to reach the goal of an HIV-free and AIDS-free generation; harmonizing the contribution of all stakeholders; developing evidence-based policies, standards and programming tools to support country-level implementation; providing support to regions and countries on strategic planning, capacity-building and implementing programmes; providing strategic information, including monitoring and evaluation, to track progress, fi ne-tune implementation and inform further programming; and supporting the strengthening of health systems for delivering an integrated package of services for women and their children and families. By implementing actions recommended by the global guidance, partners and national governments are hoping that scaling up comprehensive PMTCT programmes will prevent HIV infections among millions of women and children and lead to progress towards achieving an HIV-free and AIDS-free generation. The ultimate goal is to improve the duration of life and the well-being of women and children worldwide in the context of moving towards universal access to HIV prevention, treatment, care and support by 2010. 6 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

I. BACKGROUND 1. HIV in women and children In 2006, about 39.5 million people were living with HIV worldwide, including about 17.7 million women and 2.3 million children younger than 15 years. 1 In some regions of the world, women currently represent the population with the most rapid increase in HIV infection rates. In the hardest-hit countries of sub-saharan Africa, women, infants and young children account for more than 60% of all new HIV infections. The emergence of HIV has increased the already heavy burden of disease and death among women and children in low- and middle-income countries. This epidemic is now affecting the modest gains made in the previous decades in maternal and child survival and has had devastating effects on families, households and communities. Pregnant women living with HIV are at high risk of transmitting HIV to their infants during pregnancy, during birth or through breastfeeding. Well over 90% of new infections among infants and young children occur through motherto-child transmission. Without any interventions, between 20% and 45% of infants may become infected, with an estimated risk of 5-10% during pregnancy, 10-20% during labour and delivery, and 5-20% through breastfeeding. 2 The overall risk can be reduced to less than 2% by a package of evidence-based interventions. 3, 4 This package is now the standard of care in most high-income countries, where its implementation has led to the virtual elimination of new HIV cases among children in many settings. Even in resource-constrained settings, the use of simple and less expensive combination antiretroviral prophylactic regimens, such as short-course zidovudine (AZT) combined with single-dose nevirapine, can reduce signifi cantly in utero and intrapartum transmission. However, this effi cacy is diminished over time in breastfeeding populations due to postnatal HIV transmission through breast-milk. In sharp contrast with high-income countries, progress in scaling up effective and comprehensive services for the prevention of mother-to-child transmission of HIV (PMTCT) has been slow in most resource-constrained settings. Overall, only about 11% of pregnant women living with HIV giving birth in 2005 received antiretroviral prophylaxis. 5 Most programmes have neglected the most cost-effective approaches to reducing the proportion of infants living with HIV: preventing primary HIV infection among women of childbearing age, avoiding unintended pregnancy among women living with HIV who do not currently wish to become pregnant through family planning 6 a and introducing more effective prophylaxis and treatment. Further, despite the progress made in recent years in scaling up antiretroviral therapy in resource-constrained settings, pregnant women living with HIV have had low access to treatment relative to other populations. As a consequence, more than 1400 children under the age of 15 continue to be infected with HIV every day in resource-constrained settings, and children account for more than 10% of all new infections: a major global inequity. Without care and treatment, more than half these children will die before their second birthday. Although health systems are weak in many of the countries that have the highest burden of HIV, more than 70% of all pregnant women in these countries attend at least one antenatal care visit. 7 This provides an excellent opportunity for delivering PMTCT interventions and engaging these women and their children in a comprehensive continuum of HIV prevention, care and treatment services. Nevertheless, if PMTCT is to be successful, women must have expanded access to quality antenatal, delivery and postpartum care, and must use the existing services more frequently and earlier in pregnancy than they do currently. Implementation of PMTCT interventions can lead to an improved quality of maternal, newborn and child health services and to increased uptake of the wide range of interventions offered by these services, including essential sexual and reproductive health care. a This analysis showed that minimally reducing the prevalence of HIV infection among women of childbearing age and moderately reducing the number of unintended pregnancies among women of childbearing age can reduce infant HIV infection similarly to single-dose nevirapine-based PMTCT interventions. 7

2. Global commitments Box 1. Declaration of Commitment HIV/AIDS of the United Nations General Assembly Special Session on HIV/AIDS: preventing HIV among infants and young children By 2005, reduce the proportion of infants infected with HIV by 20 per cent, and by 50 per cent by 2010, by: ensuring that 80 per cent of pregnant women accessing antenatal care have information, counselling and other prevention services available to them, increasing the availability of and by providing access to HIV-infected women and babies to effective treatment to reduce mother-to-child transmission of HIV, as well as through effective interventions in HIV-infected women, including voluntary and confi dential counselling and testing, access to treatment, especially anti-retroviral therapy, and where appropriate, breast milk substitutes and the provision of a continuum of care. Numerous global commitments have been made in recent years to tackle the challenges of HIV and AIDS and, in particular, mother-to-child transmission of HIV. Millennium Development Goals 4, 5 and 6 (agreed to by United Nations Member States in 2000) aim to reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria and other diseases by 2015. The Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS in 2001 (Box 1) included the commitment to achieve reductions of 20% and 50% in the proportion of infants infected with HIV by 2005 and 2010 respectively in countries with generalized epidemics, while providing 80% coverage of appropriate interventions. The Prevention of Mother-to-Child Transmission (PMTCT) High Level Global Partners Forum held in December 2005 in Abuja, Nigeria resulted in a call to action whereby governments were requested to commit themselves to working together to achieve an HIV-free and AIDS-free generation by 2015. In 2005, leaders of the G8 countries agreed to work with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010. United Nations Member States endorsed this goal at the 2005 World Summit (High-level Plenary Meeting of the 60th Session of the United Nations General Assembly). At the June 2006 High-Level Meeting on AIDS, United Nations Member States agreed to work towards the broad goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010. This guidance for global scale-up of PMTCT responds to these repeated calls for action by providing a framework for global partnerships and guidance to countries on specifi c actions to take to accelerate the scale-up of PMTCT programmes in the context of moving towards universal access to HIV prevention, treatment, care and support by 2010. It is based on the United Nations recommendation of a comprehensive four-element strategy to prevent HIV among infants and young children. 8 This comprehensive approach recommends a set of key interventions to be implemented as an integral component of essential maternal, newborn and child health services. These interventions include: primary prevention of HIV among women of childbearing age; preventing unintended pregnancies among women living with HIV; preventing HIV transmission from a woman living with HIV to her infant; and providing appropriate treatment, care and support to women living with HIV and their children and families. 8 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

3. Status of implementation of PMTCT programmes Since 1998, the international community has recognized the magnitude of mother-to-child transmission of HIV and sought to reinforce countries efforts to scale up PMTCT programmes. As one of the fi rst clinical HIV interventions to be widely implemented in resource-constrained settings, PMTCT programmes helped to create the environment for the later roll-out of antiretroviral therapy and to galvanize political support for the broadening of the global response to the HIV epidemic. However, the global scale-up of PMTCT was disappointingly slow in the initial years of implementation and very uneven between countries, falling far short of the initial fi ve-year targets set in the Declaration of Commitment on HIV/AIDS of the United Nations General Assembly Special Session on HIV/AIDS. By the end of 2004, more than 100 countries had established PMTCT programmes, but only 16 of these had achieved national coverage, including just one country from sub-saharan Africa: Botswana. In contrast to many antiretroviral therapy programmes, most national PMTCT programmes lacked focused plans and targets for scaling up, and local and global resources were not optimally mobilized and coordinated. In addition, most programmes have focused almost entirely on interventions to prevent transmission from women living with HIV to their infants in antenatal care and delivery settings: these include HIV testing and counselling, antiretroviral prophylaxis, safer delivery practices and counselling and support on infant feeding. This is partly due to the lack of clear policy and operational guidance on how primary prevention of HIV among women of childbearing age and prevention of unintended pregnancies should be implemented in the context of PMTCT and within the framework of the overall national HIV prevention programmes. Concerned with this slow progress, but encouraged by successful scale-up experiences in some countries, the United Nations Children s Fund (UNICEF) and the World Health Organization (WHO), in collaboration with the Interagency Task Team on the Prevention of HIV Transmission in Pregnant Women, Mothers and their Children, convened the fi rst Prevention of Mother-to-Child Transmission (PMTCT) High Level Global Partners Forum in Abuja, Nigeria in December 2005. The delegates, representing national governments, civil society, international organizations and donor countries adopted and issued a Call to Action: Towards an HIV-free and AIDS-free generation 9, urging governments, development partners, civil society and the private sector to commit to the goal of elimination of HIV infections in infants and young children, paving the way towards an HIV-free and AIDSfree generation. In developing concrete recommendations for action by countries to accelerate the scale-up of PMTCT towards this ambitious goal, the Global Partners Forum noted several key characteristics associated with successful programmes, including: the existence of strong government commitment and ownership of the programme through active involvement of key government policy-makers to lead the programme and rally partners around one national programme and one national plan; the existence of a strong national management team and a well-functioning national coordination mechanism, which includes other key non-governmental stakeholders to guide programme design, implementation and monitoring; strengthened health systems and high-quality maternal, newborn and child health and other sexual and reproductive health care, which are essential for the effective delivery of PMTCT interventions and, in many countries, provide an opportunity sometimes the only opportunity for women to be provided with HIV prevention, treatment, care and support services; provider-initiated HIV testing and counselling in maternal, newborn and child health settings, particularly in antenatal care and labour wards, which contribute to normalizing HIV as an integral part of the package of maternal, newborn and child health services and signifi cantly increasing the uptake of HIV testing and antiretroviral prophylaxis; 9

the use of lay counsellors as an innovative solution to the shortage of health care workers in high-burden countries, which has been shown to alleviate the workload of health-care providers, to achieve good HIV testing rates and to increase coverage of PMTCT programmes; and providing a comprehensive set of services including not only a continuum of family-centred HIV care and treatment services, but also a broader array of maternal, newborn and child health services and other sexual and reproductive health care, including family planning, management of sexually transmitted infections and nutritional support. (See Annexes 1 and 2) Fig. 1. Percentage of pregnant women living with HIV and HIV-exposed infants receiving antiretroviral prophylasis for PMTCT, 2004 2005 12 11 10 Percentage 8 6 4 7 5 8 2 0 HIV positive pregnant women given ARVs 2004 2005 HIV-exposed infants receiving ARV prophylaxis Data from the 2005 Report Card on the Prevention of Mother-to-Child Transmission of HIV and Paediatric HIV Care and Treatment (a forthcoming publication of UNICEF and WHO on behalf of the Interagency Task Team on Prevention of HIV Transmission in Pregnant Women, Mothers and their Children) 10 show some encouraging trends as national programmes increasingly move beyond pilot programmes and begin to adopt many of these best practices. The 71 middle and low-income countries included in the fi nal analysis accounted for 91% of the estimated number of women living with HIV giving birth in 2005 and 87% of the estimated HIV-infected children under 15 years old in need of ART worldwide. Globally, about 11% of pregnant women living with HIV received antiretroviral drugs for PMTCT (Figure 1), ranging from 77% and 29% in eastern Europe and Latin America to 3% and 2% in western Africa and southern Asia. At least eight countries (Argentina, Belize, Botswana, Brazil, Jamaica, Russian Federation, Thailand and Ukraine) exceeded the 40% antiretroviral prophylaxis uptake mark required to achieve the PMTCT target for 2005 set by the United Nations General Assembly Special Session on HIV/AIDS of reducing new infections among children by 20%. In sub-saharan Africa, maternal antiretroviral prophylaxis uptake has more than doubled from 2004 to 2005 in three of the most severely affected countries (Namibia, South Africa and Swaziland). 10 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Fig. 2 Percentage of pregnant women living with HIV attending at least one antenatal care visit who received any antiretroviral drug regimen for PMTCT in Fiscal Year 2004 and Fiscal Year 2006 with United States Government support (both upstream and downstream) by country 100% 2006 2004 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ethiopia Nigeria Côte d'ivoire Viet Nam Mozambique Haiti Tanzania Uganda Zambia Guyana Kenya South Africa Namibia Rwanda Botswana Data from a selected group of high-burden countries supported by the United States President s Emergency Plan for AIDS Relief (PEPFAR) show continued scale-up in 2006. About 6 million pregnant women were provided with PMTCT services through the Plan. Of these, more than 533,700 received antiretroviral prophylaxis for PMTCT, preventing an estimated 101 500 HIV infections among newborns to date. 10 Overall, while current progress falls far short of achieving the targets of the United Nations General Assembly Special Session on HIV/AIDS, some national PMTCT programmes seem to be gaining momentum and capacity. However, countries need to build on the lessons learned in recent years to identify and implement innovative strategies to overcome the remaining challenges, including limited geographical expansion, high rates of loss to follow-up among women and children, and implementing the four elements of the comprehensive approach to preventing HIV among infants and young children. 11

II. PURPOSE AND INTENDED AUDIENCE OF THE GUIDANCE This document calls upon international organizations and agencies and national governments and bodies to renew their commitment, strengthen partnerships and give high priority within their respective mandates and programmes to supporting national governments in accelerating the scale up of PMTCT. It aims to foster partnerships between national governments, civil society and private-sector stakeholders, including the donor community. The guidance for global scale-up of PMTCT provides an integrated framework to assist policy-makers, programme managers and implementing partners in accelerating the scale up of high-impact comprehensive PMTCT interventions towards universal levels of coverage. It also outlines key strategies that should be considered and implemented to achieve accelerated scale up along with specifi c key actions that countries should take to reach the goal of virtually eliminating new HIV infections among infants by 2010. The guidance promotes a standard of care for PMTCT to which all women of reproductive age should have access. This standard emphasizes the importance of enrolling mothers and children in PMTCT programmes with a comprehensive continuum of care, including following up exposed children until the child s HIV status has been confi rmed and the child is 2 years old or is no longer at risk. Optimizing the impact of PMTCT programmes requires that women of reproductive age, and especially pregnant women, as well as their partners, receive HIV prevention services; that pregnant women and mothers living with HIV receive longitudinal care, treatment and support, including sexual and reproductive health care for their own needs; that HIV-exposed children (all children born to HIV-infected mothers) receive essential postnatal care, including early diagnosis of HIV, to optimize their overall survival; and that children who become infected despite PMTCT interventions can access care and treatment. Only by supporting this comprehensive set of activities can PMTCT programmes best achieve the fundamental goal of improving the AIDS-free survival of mothers and their children. Building on the comprehensive approach of the United Nations, the guidance links the acceleration of PMTCT to scaling up antiretroviral therapy. It focuses primarily on approaches that can be provided in a variety of clinical settings including maternal, newborn and child health clinics, HIV treatment centres, voluntary counselling and testing centres, sexually transmitted infection clinics and other sexual and reproductive health care, including family planning clinics. The guidance is consistent with the international initiative for the global elimination of congenital syphilis, which promotes increased access to quality maternal and newborn services and links with other maternal, newborn and child health services, including PMTCT. 11 The guidance acknowledges the important role of primary prevention of HIV among women of reproductive age and of preventing unintended pregnancies among women living with HIV. It promotes the delivery of primary prevention interventions within services related to antenatal care, postpartum care, sexual and reproductive health, voluntary counselling and testing, sexually transmitted infections and HIV. It underscores the importance of providing appropriate counselling and support to women living with HIV to make informed decision about their future reproductive life, with special attention to preventing unintended pregnancies. The guidance emphasizes the importance of supporting community-based programmes, such as prevention activities, counselling and testing activities and linking with sexual and reproductive health, including family planning and management of sexually transmitted infections. The guidance aims to ensure that HIV testing and counselling is routinely offered to all women attending antenatal, delivery and postnatal services in generalized epidemics. In concentrated and low-level HIV epidemics, the decision to make provider-initiated testing and counselling part of antenatal, childbirth and postpartum services needs to be based on the local epidemiological and social context and resources. The recommendation of an HIV test should always be accompanied by provision of necessary information and post-test counselling and made without coercion, and women should be given a clear opportunity to decline the test. HIV testing and counselling for partners, male involvement in PMTCT, and HIV interventions among children are key elements of the overall framework. Given that coverage of antenatal care is still about 70% in resource-limited settings and that very few women are assisted by a skilled attendant during delivery, 7 innovative approaches are needed to improve access to and use of antenatal care and childbirth services. In addition, national sexual and reproductive health programmes should increase access to family planning services and ensure that HIV testing and counselling is integrated into other sexual and reproductive health care, including family planning clinics. 12 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Overall, the guidance for global scale-up of PMTCT emphasizes the importance of implementing all four components of the strategic approach to the prevention of HIV infection in infants and young children to effectively address the essential health needs of pregnant women and mothers and their children and families. Box. 2. Countries accounting for more than 80% of all children living with HIV worldwide Eastern and southern Africa: Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe Western and central Africa: Cameroon, Democratic Republic of the Congo, Côte d Ivoire and Nigeria Asia and the Pacifi c: China and India Central and eastern Europe: Russian Federation and Ukraine Latin America and the Caribbean: Brazil, Dominican Republic, Haiti, Honduras and Guatemala The guidance promotes a country-targeted approach to reaching as close as possible universal access to treatment for all those who need it by 2010, noting that the PMTCT targets of the United Nations General Assembly Special Session on HIV/AIDS are far from being achieved with the current slowness in scaling up PMTCT programmes. The guidance calls for national leadership and ownership supported by emergency support from the private sector, civil society and partners. Proactive support will be provided at every stage of planning and implementation of national programmes through emergency technical missions, mobilizing resources and providing specifi c technical assistance. The primary focus will be on the countries that currently carry the highest burden of HIV among women and children, with a short-term target to support at least 20 high-burden countries (Box 2) by the end of 2007. However, support will also be provided to additional high-burden countries, as well as those with low prevalence and concentrated epidemics, particularly in countries and settings where the impact of the HIV epidemic on women and children is growing rapidly. 13

III. GUIDING PRINCIPLES The following ten principles are intended to guide the adaptation and implementation of this document at the global, regional and country levels: urgent scale-up to achieve national coverage and universal access; country ownership and accountability; emphasizing the participation of people living with HIV and communities; strong, coordinated and sustained partnerships, aiming for both impact and equity; delivering a comprehensive package of services based on the United Nations four-element strategy, including links between services and integration with maternal, newborn and child health services; giving priority to providing antiretroviral therapy to eligible pregnant women; family-centred longitudinal care; the importance of male involvement; and improving maternal and child survival. 1. Urgent scale-up to achieve national coverage and universal access PMTCT programmes need to be scaled up immediately to prevent HIV infection among women of reproductive age, unintended pregnancies among women living with HIV and mother-to-child transmission from women living with HIV to avert hundreds of thousands of new HIV infections among children; to identify and treat pregnant women needing antiretroviral therapy for their own health; and to provide care, support and treatment for children and families. To achieve this, coordinated partnerships at all levels, additional resources, decentralization of care and innovative health care delivery methods are urgently needed. 2. Country ownership and accountability It is essential that governments, working with key stakeholders including the private sector and civil society, own and drive programme planning and implementation. This needs to be supported with adequate human and fi nancial resources and guided by time-bound population-based targets to ensure accountability and sustainability. 3. Emphasizing the participation of people living with HIV and communities The participation of peers, especially women living with HIV (for example, in peer support groups) and lay counsellors, could provide opportunities to engage male partners, families and communities as a whole in implementing programmes and will be crucially important for increasing uptake of services and accelerating scaleup. 4. Strong, coordinated and sustained partnerships Long-term effective partnerships between national governments, international and national partners, civil society and networks of people living with HIV are required to harmonize and sustain action towards common goals and targets. Partners efforts should be harmonized with national government policies, strategic work plans and priorities and should support unifi ed national PMTCT programmes. 5. Aiming for both impact and equity To maximize infections averted in accordance with the targets of the United Nations General Assembly Special Session on HIV/AIDS, programmes should strategically target resources, focusing most intensively in highprevalence settings during the early phase of scale up and implementing the most effective regimens possible. At the same time, the ultimate goal of programmes should be to ensure that all women, infants and children, regardless of their educational background, socioeconomic status, race or religion, have access to proven high-impact PMTCT interventions. This implies that service delivery should be decentralized to reach as many people as possible. Additional efforts will be needed to reach marginalized population groups such as injecting drug users and sex workers within and outside the public health sector. HIV-related stigma, discrimination and gender-based violence need to be addressed to create a conducive environment for women and their families to gain access to services. 14 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

6. Delivering a comprehensive package of services based on the United Nations fourelement strategy, including links between services and integration with maternal, newborn and child health services Achieving the goal of eliminating HIV among infants and young children requires that programmes adopt the United Nations comprehensive approach to the prevention of HIV infection among infants and young children, which is intended to address a wide range of prevention, care, treatment and support services along a continuum of care from pregnancy through childhood. National programmes should establish the necessary links to ensure large-scale access to a comprehensive package of services defi ned according to local context, including epidemiology and available resources. Specifi cally, PMTCT should be strongly linked to HIV care and antiretroviral therapy and integrated into existing maternal, newborn and child health services, other sexual and reproductive health programmes, services for sexually transmitted infections and voluntary counselling and testing services targeting most at-risk groups. Integrating HIV and existing reproductive health care, specifi cally family planning, has the potential to draw on the strengths and resources of both programmes in order to help women learn their HIV status and to make better informed decision about their future reproductive life, including the avoidance of unwanted pregnancies. HIV prevention and care programmes are rapidly expanding, and integrating family planning services into these programmes can increase access to sexual and reproductive health care and dramatically enhance the public health impact of the HIV programmes. 7. Giving priority to providing antiretroviral therapy to eligible pregnant women Achieving the PMTCT targets of the United Nations General Assembly Special Session on HIV/AIDS and improving overall maternal and child survival requires intensifying focus on improving access to antiretroviral therapy for pregnant women living with HIV who need it for their own health, thereby providing highly effective PMTCT interventions for women with the highest risk of transmission. Currently, this subset of women has disproportionately low access to antiretroviral therapy in most settings, and additional effort and resources will be required to make operational the links between PMTCT and antiretroviral therapy towards the goal of achieving universal access to treatment for pregnant women living with HIV. 8. Family-centered longitudinal care Identifying women living with HIV in PMTCT programmes should be used as an entry point to recommend HIV testing and counselling to other family members, especially their sexual partners and children, and to provide those in need with a wide range of HIV prevention, treatment, care and support services. 9. Importance of male involvement Globally, male involvement has been recognized as a priority focus area to be strengthened in PMTCT. This can be accomplished by encouraging couples counselling and mutual disclosure. This will benefi t adherence, improve uptake and continuation of family planning methods and provide family-centred care and treatment. Male partners who are diagnosed as being HIV-positive should be given or referred to appropriate treatment and care. 10. Improving maternal and child survival To achieve the overall goal of improving maternal and child survival, all PMTCT programmes should focus not only on preventing transmission to infants but also on optimizing infant feeding practices; providing basic preventive care to mothers and infants, including nutritional support; providing access to other sexual and reproductive health care, including family planning; and facilitating access to treatment for mothers and children in need. 15

IV. STANDARD OF CARE Women and children attending maternal, newborn and child health services should be provided with an integrated package of services including those related to HIV, malaria, tuberculosis, sexually transmitted infections, family planning, immunization, nutritional support and other services that are essential for improving health outcomes. For many women, pregnancy and child care constitute the two main reasons they come into contact with the health system. HIV prevention, care and treatment including PMTCT should be integrated into maternal, newborn and child health and other sexual and reproductive health care as a core component of the package of services delivered to women and children. The services outlined in Annexes 1 and 2 are recommended as the global standard of care for PMTCT. Regions and countries should adapt this package of services according to the local epidemiology and operational contexts (including the capacity of health systems to respond and the resources available). 16 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

V. GOAL AND TARGETS The guidance reiterates internationally agreed commitments and targets and calls for urgent action to deliver on them. It primarily aims to provide guidance to countries and partners on action to be taken to reach the PMTCT targets of the United Nations General Assembly Special Session on HIV/AIDS. 1. Goal The goal of this guidance for global scale up of PMTCT is to improve maternal and child survival by achieving universal access to comprehensive PMTCT services to pave the way towards an HIV-free and AIDS-free generation by 2015. 2. Impact target for 2010 The target for 2010 is a 50% reduction in the proportion of infants newly infected with HIV compared with 2001 (United Nations General Assembly Special Session on HIV/AIDS). Coverage levels of key PMTCT-related services for the 2010 PMTCT targets of the United Nations General Assembly Special Session on HIV/AIDS Adequate coverage levels must be met for PMTCT-related interventions to reach the goal and achieve the targets mentioned above. The Declaration of Commitment on HIV/AIDS of the United Nations General Assembly Special Session on HIV/AIDS aims to reduce the proportion of infants infected with HIV: by: ensuring that 80 per cent of pregnant women accessing antenatal care have information, counselling and other prevention services available to them, increasing the availability of and by providing access to HIV-infected women and babies to effective treatment to reduce mother-to-child transmission of HIV, as well as through effective interventions in HIV-infected women, including voluntary and confi dential counselling and testing, access to treatment, especially anti-retroviral therapy, and where appropriate, breast milk substitutes and the provision of a continuum of care. Building on this, the following programme coverage levels are proposed to guide country level efforts. At least 80% of all pregnant women attending antenatal care are provided with information on PMTCT. At least 80% of all pregnant women attending antenatal care are tested for HIV, including those previously confi rmed to be living with HIV. At least 80% of pregnant women living with HIV receive antiretroviral prophylaxis or antiretroviral therapy to reduce the risk of mother-to-child transmission. At least 80% of eligible pregnant women living with HIV receive antiretroviral therapy for their own health. At least 80% of infants born to women living with HIV receive co-trimoxazole prophylaxis. At least 80% of pregnant women living with HIV receive infant feeding counselling and support at the fi rst infant follow-up visit. At least 80% of women living with HIV are successfully referred and enrolled in comprehensive longitudinal care and treatment. At least 80% of infants born to women living with HIV receive a virological HIV test within two months of birth. To track progress in the implementation of all four elements of the United Nations comprehensive approach to preventing HIV among infants and young children, countries are encouraged to defi ne additional coverage targets for primary prevention and family planning. Countries could consider the following: the percentage of male partners of women diagnosed as HIV-negative through PMTCT services who are tested and counselled for HIV; the percentage of male partners of women diagnosed as being HIV-positive through PMTCT services who are tested and counselled for HIV; and 17

the percentage of women living with HIV enrolled in PMTCT and care and treatment services who receive family planning services (either on site or through referrals). Recent evidence shows that exclusive breastfeeding carries a lower risk of HIV transmission than breastfeeding combined with other fl uids or foods. Evidence is also growing that high-quality counselling and support for women living with HIV and consistent messages at the population level can achieve high rates of exclusive breastfeeding. A consensus statement on HIV and infant feeding adopted in October 2006 12 recommends exclusive breastfeeding for women living with HIV for the fi rst six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time. The statement also recommends that women living with HIV avoid all breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe. Thus, countries might consider specifi c targets on actual infant feeding practices by women living with HIV such as the percentage of mothers living with HIV who practise either exclusive breastfeeding or replacement feeding at specifi ed time points in the fi rst months of life. 18 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

VI. RECOMMENDED PRIORITY STRATEGIES AND ACTIONS AT COUNTRY LEVEL 1. Demonstrated government leadership, commitment and accountability to deliver on the goal of universal access to PMTCT and HIV care for children Recommended key actions PMTCT as a key component of national HIV plan. Address mother-to-child transmission of HIV in national HIV plans in all epidemic settings. National coordination. Establish a government-driven coordination body for PMTCT and HIV care for children and mechanisms bringing together key government departments, especially maternal, newborn and child health, family and reproductive health divisions, partner organizations, civil society representatives and groups of people living with HIV involved in PMTCT and implementing HIV care for children. Standard care package. Based on HIV prevalence, defi ne a standard package of PMTCT services and HIV care services for children at the different levels of the health system, including in primary care health facilities and at the community level, with the aim of improving maternal, neonatal and child survival as well as HIV care and treatment for children (Annexes 1 3). Numerical targets. Develop numerical population-based targets in accordance with universal access by 2010 and establish benchmarks. These targets should include comprehensive PMTCT targets, encompassing targets for primary prevention of HIV among women of childbearing age, prevention of unintended pregnancies and the treatment of pregnant women and children. Plan for scale up. Develop and implement one comprehensive integrated and costed multi-year evidencebased national PMTCT and HIV care for children scale up plan with numerical population-based targets and specifi c strategies and actions for strengthening health systems (including human resources; monitoring and evaluation; and supplies) to achieve scaled-up implementation. Plan for monitoring and evaluation. Develop and implement, in the framework of the national scale-up plan, a monitoring and evaluation plan, including harmonized tools and a programme review by 2010, to measure and assess performance, track progress and fi ne-tune programmes. Accountability. Institute country-specifi c accountability mechanisms and performance-based management and fi nancing systems at all structural levels (national, sub national and site levels) that clearly defi ne roles and responsibilities, reporting channels and timelines to ensure that managers contribute and are held accountable for achieving the targets set in national and district plans. Mobilize resources. Create a strategy within government for mobilizing and reallocating additional resources (including creating fi scal space, defi ned by Heller 13 as the availability of budgetary room that allows a government to provide resources for a desired purpose without any prejudice to the sustainability of a government s fi nancial position ) to secure sustainable fi nancing for implementing PMTCT and HIV care for children. 2. District-driven delivery of a standard package of comprehensive services As implementing agencies, districts will ensure that this standard package is fully integrated into HIV care and treatment services, maternal, newborn and child health and other sexual and reproductive health care. Recommended key actions Map and assess readiness, improve and monitor the capacity of all the relevant health facilities (government and nongovernmental), including the potential need for strengthening the health system, improving infrastructure and bolstering community-level support services within health districts. Develop and implement district scale-up plans (including the primary health care level) that are aligned with the national scale up plan and that clearly defi ne district-specifi c population-based numerical targets and consider the district s epidemiological context and health delivery system and capacity. Develop and assess models for delivering comprehensive PMTCT services and HIV care for children to be rolled out to the lowest level of the health system. Develop human capacity at all levels through training of core groups of master trainers at relevant levels and orientation of district health teams in programme planning, implementation, monitoring and evaluation and integrated supervision of quality improvement. 19

3. Institutionalizing provider-initiated HIV testing and counselling in maternal, newborn and child health settings Recommended key actions Recommend HIV testing and counselling to women as a routine component of the package of care in all antenatal, childbirth, postpartum and paediatric care settings in generalized epidemic settings. In settings with low and concentrated epidemics, provider-initiated HIV testing and counselling may be considered for pregnant women identifi ed as being at higher risk of HIV exposure according to national or local criteria. In any case, information about mother-to-child transmission of HIV and HIV testing and counselling should be given to all pregnant women during antenatal information sessions. For children, the overarching principle is to ensure their best interests and optimal health outcomes. In all epidemic settings, HIV testing and counselling should be: recommended as part of the routine follow-up care for all children born to women living with HIV; recommended for children presenting with signs and symptoms or health conditions potentially associated with HIV or AIDS, including tuberculosis; and recommended for children with suboptimal growth or malnutrition or malnourished children who are not responding to appropriate nutritional therapy. Recommend HIV testing and counselling for all sick children seen in paediatric health services in generalized epidemic settings. Ensure that wherever provider-initiated HIV testing and counselling is implemented as part of PMTCT services, there is access to a minimum package of HIV-related prevention, care, treatment and support services for women, children and families, whether on-site or through referral. Develop supportive social, policy and legal frameworks and competencies to support the implementation of provider-initiated HIV testing and counselling for all women attending antenatal care, childbirth and postpartum health care services and their infants and children. This should include developing and/or strengthening community or social services and efforts to decrease the incidence and risk of social stigma, discrimination and violence against women. 4. Institutionalizing longitudinal HIV care management in maternal, newborn and child health settings Recommended key actions Revise existing policies, guidelines and tools related to pregnancy, childbirth, postpartum and family planning to address the specifi c needs of women living with HIV, including HIV follow-up care and treatment and access to sexual and reproductive health care tailored to their needs. Revise HIV care and treatment, PMTCT, and HIV testing and counselling guidelines and tools to address prevention with positives, and sexual and reproductive health needs of women living with HIV. Institutionalize systematic follow-up from the point of fi rst contact throughout pregnancy, delivery and postpartum, including early childhood, until the child s HIV status has been ascertained and both the mother and child are referred for follow-up care and treatment. Build capacity within antenatal care and postnatal care settings in hospitals and primary facilities (including training, equipment and referrals) to carry out clinical and immunological assessment of pregnant women and children living with HIV and, where appropriate, to initiate antiretroviral therapy and co-trimoxazole prophylaxis. Revise policies, guidelines and tools (including under-5 cards with clinical information on children younger than 5 years old) and the organization of service delivery to institutionalize systematic follow-up of HIV-exposed children in child health services, including well-baby clinics and programmes such as immunization, the Integrated Management of Childhood Illness (IMCI) approach and assistance for children with severe disabilities, care facilities for children and antiretroviral therapy centres. 20 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Build capacity, including policies, guidelines, human resources, early diagnosis of HIV among infants and referrals, within PMTCT and clinical care settings for children for the early diagnosis of HIV infection in HIVexposed children to ensure timely access to appropriate care, treatment and nutritional support. 5. Increasing access to antiretroviral therapy for pregnant women, mothers and their children and families in the context of PMTCT Recommended key actions Revise national PMTCT and antiretroviral therapy guidelines to include more effi cacious prophylactic antiretroviral regimens for PMTCT and antiretroviral therapy for eligible pregnant women living with HIV, in accordance with the most current WHO guidelines for treating pregnant women and preventing HIV infection among infants and young children. Facilitate bringing antiretroviral therapy closer to PMTCT through integrated policies, guidelines and programme coordination; synchronized implementation of PMTCT and plans for scaling up antiretroviral therapy, networking PMTCT sites around antiretroviral therapy centres and integrating PMTCT in antiretroviral therapy centres. Build capacity, including human resources, training, guidelines and tools, within all existing antiretroviral therapy centres for the delivery of a comprehensive package of HIV care, treatment and support for children. Revise policies, guidelines, tools and the organization of service delivery and develop appropriate competencies to ensure effective referral systems and links between PMTCT and antiretroviral therapy, including health facilities as well as community-based services. 6. Strengthening infant feeding and nutrition advice, counselling and support for women and their children and families in the context of PMTCT and HIV care for children Recommended key actions Develop supportive policies and build capacity to revitalize breastfeeding protection, promotion and support in the general population. Integrate nutrition support as a component of the package of services for rolling out antiretroviral therapy and promoting innovative approaches such as nutritional kits and ready-to-use food. Build capacity and develop competencies to actively support women living with HIV who choose to exclusively breastfeed, and to make replacement feeding safer for women who choose that option. Provide baseline nutrition and dietary assessment as a routine component of the package of care for women living with HIV and their children in all antenatal, childbirth and postpartum care settings. Ensure that appropriate messages on the importance of infant feeding and nutrition are incorporated into existing communication plans, especially for lactating women living with HIV and children living with HIV. Build the capacity of health and community-based service providers on nutrition counselling and support, with a focus on specifi c needs of women living with HIV, their children and families. Enhance public awareness of the importance of improving nutrition for all women, regardless of their HIV status. Special attention will be paid to pregnant and lactating women living with HIV and their infants and young children, by incorporating high-quality messages, counselling and services for infant and young child feeding in the context of HIV in existing behaviour change communication interventions. 7. Operationalizing the link between the delivery of PMTCT and of sexual and reproductive health care The provision of comprehensive PMTCT services requires reorganizing and reorienting health systems to ensure the delivery of routine maternal, newborn and child health services and other sexual and reproductive health care, and a set of essential interventions for HIV prevention, treatment and care. Meeting the contraceptive needs of women living with HIV and those at-risk requires providers who are adequately trained to seek out and understand 21

client desires and to counsel them effectively on their reproductive choices. As in traditional family planning, programmes, informed-choice counselling must be the cornerstone of contraceptive services in HIV-service delivery settings. Women living with HIV, like all women, have the right to make reproductive choices for themselves, and care must be taken to ensure that they are not coerced into a particular reproductive decision. For those women who do not wish to become pregnant, providers must be able to discuss feasible, safe and effective contraceptive options. Implementation and scale up require working at the district level and improving the links and coordination between different programmes. This involves various programmes, points of service delivery and health-care, as well as community-level service providers. Key points of service delivery include antenatal care settings, maternity wards, tuberculosis clinics, family planning, sexually transmitted infections, youth- and adolescent-friendly settings, HIV including antiretroviral therapy and community-based services (Annex 4). Recommended key actions Redefi ne the roles, responsibilities and accountabilities of the services related to sexual and reproductive health, sexually transmitted infections and voluntary counselling and testing to enable the delivery of a comprehensive package of PMTCT services and HIV care for children. Support sexual and reproductive health programmes (through advocacy, mobilizing resources, technical assistance and implementation) to increase the overall availability and quality of sexual and reproductive health care (including counselling on HIV prevention; couple counselling; condom promotion, distribution and guidance on negotiation and consistent and correct use; screening for and treating sexually transmitted infections and family planning counselling and related services, including commodities), particularly for women living with HIV and their partners. Integrate HIV testing and counselling into sexual and reproductive health settings, including family planning services, to prevent HIV infection among childbearing women and their sexual partners and provide highquality sexual and reproductive health care to women living with HIV that meet their needs. Integrate sexual and reproductive health care into antiretroviral therapy centres or strengthen referral links between these two service delivery points so that women living with HIV and their partners can meet their comprehensive sexual and reproductive health concerns, including preventing unintended pregnancies. Provide family planning counselling and education during antenatal care in all settings providing PMTCT. Provide family planning counselling and methods in the postpartum period in all settings providing PMTCT to all women, with specifi c attention to the needs of women living with HIV, either on site or through referral. Develop appropriate guidelines, tools and competencies to support the provision of family planning and other sexual and reproductive health care as a critical component of the continuum of care and support for women living with HIV in the context of PMTCT and HIV care for children. 8. Empowering and linking with communities Recommended key actions Defi ne a standard package of interventions within the comprehensive package of HIV prevention and care services to be provided by community-based service providers in the context of PMTCT and HIV care, treatment and support for children. Establish district-wide systems for linking services to community-based providers to enhance community awareness, HIV prevention, drug adherence and utilization of services. Build capacity and provide technical and fi nancial support as necessary to community-based organizations (non-governmental organizations, faith-based organizations and associations or networks of people living with HIV) for planning and delivering interventions involving PMTCT and HIV care for children at both the community and health facility levels. 22 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Promote and facilitate the active participation of people living with HIV, especially women and mothers living with HIV, in planning and delivering services, advocacy and community engagement. Promote and support male-friendly models for delivering HIV services within maternal, newborn and child health and other sexual and reproductive health care, and the participation of male partners in interventions involving PMTCT and HIV care for children. Develop and support the implementation of culturally appropriate policies and programmatic approaches to minimizing HIV-related domestic violence, stigma and discrimination in the context of PMTCT and HIV care for children, including supporting women living with HIV in disclosing their HIV status to partners and family members. 23

VII. ROLES OF PARTNERS The partners endorsing this guidance document commit themselves to revitalizing the global PMTCT agenda by: helping to galvanize political will and the commitment of national governments; giving priority to funding and technical support for scaling up PMTCT and care for children; harmonizing the contribution of all stakeholders; fully supporting the implementation of PMTCT and HIV care for children; and promoting the coordination of PMTCT with the scale-up of antiretroviral therapy. They will seek to use all opportunities to make progress on the global PMTCT agenda, including using the support of initiatives such as PEPFAR, GFATM, the World Bank Multi-Country HIV/AIDS Program for Africa and UNITAID (the International Drug Purchase Facility), and other initiatives and funding sources and will contribute according to their capacity, mandate, comparative advantages and technical expertise. The primary focus of their action will be to support activities at the national level in the countries that carry the highest burden of HIV among women and children with the development and implementation of national plans to scale up PMTCT and HIV care for children by the end of 2007. A secondary focus of partner action will be: to mobilize the international community, galvanize political will and mobilize resources to reach the goal of an HIV-free and AIDS-free generation; to develop evidence-based policies, standards and programming tools to support country-level implementation; to support regional and national planning and capacity-building; to provide strategic information, including monitoring and evaluation to track progress and inform further programming; and to support the strengthening of health systems. 1. Concerted response by partners at the country level to maximize their support to national governments At the national level, partners actions will be conducted in the context of the three ones principles: one agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority with a broad-based multisectoral mandate; and one agreed country-level monitoring and evaluation system for HIV/AIDS. Partners will mainly contribute to implementing the guidance in countries in the following areas: advocacy, partnership development to commit national governments to the goal of an HIV-free and AIDS-free generation and support for national-level planning; mobilizing resources, harmonization and allocating resources for implementing programmes; providing technical assistance to support and guide country-level implementation; strengthening the health system for delivering comprehensive PMTCT services, including integrating PMTCT into maternal, newborn and child health, family planning and sexual and reproductive health care; and supporting the collection of strategic information to track progress and improve programming. 24 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

a. Advocacy, partnership development and planning support Partners will support the development of national leadership and ownership and build broad support among local stakeholders, including the private sector and civil society, for developing and implementing national plans for scaling up PMTCT and HIV care for children. Partners endorsing this guidance document commit themselves to: working with national governments as well as regional bodies and institutions to ensure that regional and national political commitments are translated into concrete initiatives to accelerate the scale-up of national programmes for PMTCT and HIV care for children; supporting the coordination, planning and implementation of PMTCT and HIV care for children through national coordination mechanisms, including seeking to ensure coordination and cooperation between the planning and implementation of HIV, maternal, newborn and child health and sexual and reproductive health care and to involve all partners, agencies and key stakeholders involved in PMTCT and HIV care for children; identifying and supporting champions of PMTCT and HIV care for children to raise the visibility of the issue and catalyse and ensure the sustainability of action at all levels; and seeking to ensure that PMTCT and HIV care for children are included on the agenda and addressed at relevant meetings, events, workshops and conferences. b. Mobilizing and allocating resources The partners will support countries in mobilizing, allocating and contributing to coordinating resources for PMTCT and HIV care for children. Country scale-up plans will identify funding gaps and be used to develop and implement strategies for mobilizing and harmonizing resources. Specifi c actions that partners will support include: providing technical assistance for mapping available resources and identifying funding gaps for the full implementation of national scale-up plans through strategic planning exercises; assisting national governments in mobilizing resources, strategic allocation and effective utilization to support the implementation of plans for scaling up PMTCT and HIV care for children; and supporting the implementation of national scale up plans through joint work planning and budgeting between partners, including exploring opportunities with current main initiatives, such as those supported by PEPFAR, GFFATM, and the World Bank Multi-Country HIV/AIDS Program for Africa, to avoid duplication and ensure synergy at the country level. c. Technical assistance to support and guide country-level implementation Partners will provide timely and sustained technical assistance, building on ongoing initiatives. Specifi c actions include: providing guidance and technical assistance for developing national plans for scaling up PMTCT and HIV care for children, including facility- and population-based numerical targets; providing technical and fi nancial support for developing sustainable national capacity in programme management and coordination, service delivery and monitoring and evaluation; providing assistance to countries in setting national numerical targets in accordance with the goal of universal access to HIV prevention, treatment, care and support services; supporting and conducting, on an ad hoc basis, joint technical missions to support strategic planning, national programme implementation and programme reviews; and actively working at the country level to support scale-up. 25

2. Setting the global agenda for PMTCT and HIV care for children and maintaining momentum The contribution of partners at the global level will be driven by a shared vision and goals. The primary goal is to set the global agenda and maintain momentum by galvanizing a collective contribution within the scope of the various global commitments. Partners will collaborate at the global level in the following areas by: undertaking global advocacy to galvanize political will and mobilize resources; developing evidence-based policies, guidelines and programming tools to support country-level implementation; organizing regional and national planning and capacity-building; supporting the generation of evidence-based strategic information to track progress, fi ne-tune programming and guide policies; and supporting the strengthening of health systems for the effective delivery of standards of care for PMTCT within maternal, newborn and child health and other sexual and reproductive health care. a. Mobilizing the international community, galvanizing political will and mobilizing resources for an HIV-free and AIDS-free generation Partners will mobilize the international community around the goal of an HIV-free and AIDS-free generation. They will work together at the global level to create an enabling environment for concerted and coordinated partnerships to guide and support national governments efforts to scale up PMTCT and HIV care for children. Specifi c actions include: spearheading global advocacy to mobilize partners and donors committed to global health issues on HIV and maternal, newborn and child health around the implementation of this global guidance for eliminating HIV among infants and young children; setting the global agenda on PMTCT, HIV care for children and maternal, newborn and child health to support and accelerate the scale up of national programmes for PMTCT and HIV care for children in accordance with the ultimate goal of improving maternal, newborn and child health; and improving the coordination of global efforts in PMTCT and HIV care for children through global coordination bodies and mechanisms, with a focus on the leading role of the Interagency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. b. Develop evidence-based policies, guidelines and programming tools to support country-level implementation Partners endorsing this guidance document are committed to: developing and promoting an essential package of interventions for PMTCT and the care, treatment and support of women, infants and their families to support country efforts for programme implementation, including constantly reviewing and revising the package in the light of emerging evidence and country-specifi c context; developing and providing support for adapting and implementing normative and operational guides to support the planning and implementation of a global standard of care for PMTCT and HIV care for children to be delivered in an integrated way within the health sector using a family-centred public health approach; b providing assistance in implementing the fi ve areas of the HIV and Infant Feeding Framework for Priority Action 14 c within the context of the national scale up plan; b c Partners will develop new tools to complement the various tools already available at the global, regional and country levels pertaining to HIV, safe motherhood and child and adolescent health, including the Integrated Management of Childhood Illness (IMCI) and the Integrated Management of Adult and Adolescent Illness (IMAI), to support planning, programming and implementation. Specifi c attention will be paid to establishing chronic HIV care with antiretroviral therapy and PMTCT in antenatal and postpartum clinics and at the health centre level. The Framework proposes for consideration by governments the following priority actions related to infant and young child feeding: 1) develop or revise (as the case may be) a comprehensive national policy on infant and young child feeding that includes HIV and infant feeding; 2) implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions; 3) intensify efforts to protect, promote and support appropriate infant and young child feeding practices in general, while recognizing HIV as one of several exceptionally diffi cult circumstances; 4) provide adequate support to women living with HIV to enable them to select the best feeding option for themselves and their babies and to successfully carry out their infant feeding decisions; and 5) support research on HIV and infant feeding including operations research, learning and monitoring and evaluation at all levels and disseminate the fi ndings. 26 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

providing technical assistance and helping to mobilize resources for implementing provider-initiated testing and counselling in the context of PMTCT and HIV care for children, based on a country s epidemiological and social context; providing technical assistance and supporting resource mobilization to institutionalize HIV chronic care management in maternal, newborn and child health services, including access to antiretroviral therapy in highburden countries; and providing policy and operational guidance and technical assistance and supporting resource mobilization to strengthen and improve the implementation of primary prevention of HIV among women of reproductive age and to prevent unintended pregnancies among women living with HIV in the context of PMTCT. c. Support regional and national planning and capacity-building for the delivery of PMTCT and HIV care for children within maternal, newborn and child health services Partners will support regions and national governments in assessing and planning for the development of innovative workforce models for delivering comprehensive PMTCT services. Specifi c actions include: supporting and conducting, on an ad hoc basis, regional and national planning and capacity-building through regional or subregional workshops involving regional experts, national programme mangers and the technical staff of partner organizations; and providing guidance and technical assistance on innovative approaches to human resource planning, including management and coordination, pre-service and in-service training, retention, task-shifting and motivating staff. d. Support evidence-based strategic information to track progress, improve programming and guide policies Partners will provide the necessary technical and fi nancial support to countries to establish and scale up reliable progress-tracking mechanisms and systems including national monitoring and evaluation plans to enable fi netuning and further programming of PMTCT and HIV care for children. A focus on results, measuring results, and releasing any reporting of results will enhance these fi ne-tuning and reprogramming efforts. Support will also be provided to carry out operations research and to adopt learning-by-doing approaches. Specifi c actions include: providing guidance and technical assistance to strengthen the national capacity to develop progress-tracking mechanisms and tools; providing technical and fi nancial support for learning-by-doing approaches through regional, subregional and country mechanisms and structures, including networks and centres of excellence; documenting and disseminating best practices and successful models; and defi ning priorities and mobilizing resources for PMTCT-related research, including operations research. e. Support the strengthening of health systems for delivering a standard of care for PMTCT within maternal, newborn and child health services Scaling up PMTCT and HIV care for children requires a health system that can take on a wide range of prevention, care, treatment and support services for women and their children. Partners will support the planning and implementation of a global standard of care for PMTCT to be delivered in an integrated way within maternal, newborn and child health and other sexual and reproductive health care using a family-centred public health approach. Partners endorsing this guidance document are committed to: strengthening their investment in the primary health care system by rehabilitating or upgrading existing infrastructure; and providing technical assistance and fi nancial support for institutional and human capacity-building to improve the quality of and access to maternal, newborn and child health services and related sexual and reproductive health care. 27

VIII. CONCLUSION Comprehensive and widely available PMTCT programmes could substantially improve the quality and duration of life among women and children worldwide. Implementing the strategies and actions presented in this guidance will contribute to rapidly expanding services to achieve the goal of universal access to HIV prevention, treatment, care and support by 2010 and will make progress towards eliminating HIV infections among infants and young children by 2015. This will require the concerted efforts of governments and their partners to maximize the utilization of limited expertise and resources towards a common national goal. The ultimate benefi ts of doing so will be substantial: children born to millions of women will avoid HIV transmission if the relatively simple interventions to reduce HIV among infants and young children are implemented. Even more children will have the benefi t of growing up with the security and support of their parents even if they are living with HIV. Women will benefi t from avoiding HIV transmission and from increased treatment, care and support for those living with HIV, thereby reducing maternal morbidity and mortality. These outcomes are essential for reducing the impact of HIV globally and for enhancing human dignity, security and development. 28 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

REFERENCES 1. UNAIDS/WHO AIDS epidemic update: December 2006. Geneva, UNAIDS, 2006 (http://www.unaids.org/en/ HIV_data/epi2006/default.asp, accessed 13 June 2007). 2. De Cock KM et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. Journal of the American Medical Association, 2000, 283:1175 1182. 3. Dorenbaum A et al. Two-dose intra-partum/newborn nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission: a randomized trial. Journal of the American Medical Association, 2002, 288:189 198. 4. Cooper ER et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1 infected women and prevention of perinatal HIV-1 transmission. Journal of Acquired Immune Defi ciency Syndromes, 2002, 29:484 494. 5. WHO, UNAIDS and UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report, April 2007. Geneva, World Health Organization, 2007 (http://www.who.int/hiv/en, accessed 13 June 2007). 6. Sweat MD et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. AIDS, 2004, 18:1661 1671. 7. WHO and UNICEF. Antenatal care in developing countries promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 1990 2001. Geneva, World Health Organization, 2003 (http:// www.who.int/reproductive-health/publications/antenatal_care/index.html, accessed 13 June 2007). 8. Strategic approaches to the prevention of HIV infection in infants: report of a WHO meeting, Morges, Switzerland, 20 22 March 2002. Geneva, World Health Organization, 2003 (http://www.who.int/hiv/pub/mtct/pub35/en, accessed 13 June 2007). 9. Call to Action: Towards an HIV-free and AIDS-free generation. Prevention of Mother to Child Transmission (PMTCT) High Level Global Partners Forum, Abuja, Nigeria, December 3, 2005. Geneva, World Health Organization, 2005 (http://www.who.int/hiv/mtct/pmtct_calltoaction.pdf, accessed 13 June 2007). 10. The power of partnerships: the President s Emergency Plan for AIDS Relief third annual report to Congress. Washington, DC, Offi ce of the United States Global AIDS Coordinator, 2007 (http://www.pepfar.gov/press/ c21604.htm, accessed 13 June 2007). 11. Action for the global elimination of congenital syphilis: rationale and strategy. Geneva, World Health Organization, forthcoming. 12. WHO HIV and Infant Feeding Technical Consultation held on behalf of the Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children, Geneva, October 25 27, 2006: consensus statement. Geneva, World Health Organization, 2006 (http://www.who.int/child-adolescent-health/ publications/nutrition/consensus_statement.htm, accessed 13 June 2007). 13. Heller PS. Understanding fi scal space. Washington, DC, International Monetary Fund, 2005 (http://www.imf. org/external/pubs/ft/pdp/2005/pdp04.pdf, accessed 13 June 2007). 14. HIV and Infant Feeding Framework for Priority Action. Geneva, World Health Organization, 2003 (http://www.who. int/child-adolescent-health/publications/nutrition/hiv_if_framework.htm, accessed 13 June 2007). 29

ANNEXES Annex 1. Package of essential services for high-quality maternal care Package of routine quality antenatal and postpartum care for all women regardless of HIV status 1. Health education, information on prevention and care for HIV and sexually transmitted infections, including safer sex practices, pregnancy including antenatal care, birth planning and delivery assistance, malaria prevention, optimal infant feeding; family planning counselling and related services 2. Provider-initiated HIV testing and counselling, including HIV testing and counselling for women of unknown status at labour and delivery or postpartum 3. Couple and partner HIV testing and counselling, including support for disclosure 4. Promotion and provision of male and female condoms 5. HIV-related gender-based violence screening 6. Obstetric care, including history taking and physical examination 7. Maternal nutritional support 8. Counselling on infant feeding 9. Psychosocial support 10. Birth planning, birth preparedness (including pregnancy and postpartum danger signs), including skilled birth attendants 11. Tetanus vaccination 12. Iron and folate supplementation 13. Syphilis screening and management of sexually transmitted infections 14. Risk reduction interventions for injecting drug users Additional package of services for women living with HIV 1. Additional counselling and support to encourage partner testing, adoption of risk reduction and disclosure 2. Clinical evaluation, including clinical staging of HIV disease 3. Immunological assessment (CD4 cell count) where available 4. Antiretroviral therapy when indicated 5. Counselling and support on infant feeding based on knowledge of HIV status 6. Antiretroviral prophylaxis for PMTCT provided during the antepartum, intrapartum and postpartum period 7. Co-trimoxazole prophylaxis where indicated 8. Additional counselling and provision of services as appropriate to prevent unintended pregnancies 9. Supportive care, including adherence support 10. Additional counselling and provision of services as appropriate to prevent unintended pregnancies 11. Tuberculosis screening and treatment when indicated; preventive therapy (isoniazid prophylaxis) when appropriate 12. Advice and support on other prevention interventions, such as safe drinking-water 13. Supportive care, including adherence support and palliative care and symptom management 30 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Additional package of services for all women regardless of HIV status in specifi c settings 1. Malaria prevention and treatment 2. Counselling, psychosocial support and referral for women who are at risk of or have experienced violence 3. Counselling and referral for women with a history of harmful alcohol or drug use 4. De-worming 5. Consider retesting late in pregnancy where feasible in generalized epidemics Annex 2. Essential postnatal care for HIV-exposed infants and young children 1. Completion of antiretroviral prophylaxis regimen as necessary 2. Routine newborn and infant care, including routine immunization and growth monitoring 3. Co-trimoxazole prophylaxis 4. Early HIV diagnostic testing and diagnosis of HIV-related conditions 5. Continued infant feeding counselling and support, especially after HIV testing and at 6 months 6. Nutritional support throughout the fi rst year of life, including support for optimal infant feeding practices and provision of nutritional supplements and replacement foods if indicated 7. Antiretroviral therapy for children living with HIV, when indicated 8. Treatment monitoring for all children receiving antiretroviral therapy 9. Isoniazid prophylaxis when indicated 10. Counselling on adherence support for caregivers 11. Malaria prevention and treatment where indicated 12. Diagnosis and management of common childhood infections and conditions and Integrated Management of Childhood Illness (IMCI) 13. Diagnosis and management of tuberculosis and other opportunistic infections Annex 3. Antiretroviral regimens recommended by WHO for treating pregnant women and preventing HIV infection in infants Promoting more effi cacious ARV regimens WHO recommends antiretroviral therapy (ART) for all pregnant women who are eligible for treatment. Initiation of ART in pregnant women will address not only their health needs but will also signifi cantly reduce HIV transmission to their infants. In addition, by securing the health of women, it also improves child wellbeing and survival. For pregnant women with HIV who do not yet require ART, antiretroviral prophylactic regimens are recommended for MTCT prevention. The recommended regimens by WHO are based around AZT (from 28 weeks of pregnancy or as soon as possible thereafter) plus single-dose nevirapine plus maternal 7- day tail of AZT and 3 TC and one-week AZT for the infant. 31

Annex 4. Key entry points and interventions: primary prevention of HIV among women of childbearing age and prevention of unintended pregnancies among women living with HIV Selecting service delivery entry points will depend on the characteristics of the AIDS epidemic (concentrated versus generalized etc.) and access and utilization of health and related services in each country. Priority entry points include antenatal, maternity and postpartum care, family planning, HIV care and treatment (for adults and children), sexually transmitted infections and voluntary counselling and testing. Additional entry points as appropriate include child immunization; gender-based violence; youth-friendly, community-based outreach; prevention and treatment for drug users; support groups of people living with HIV, tuberculosis, well-baby followup, post-abortion care, workplace, etc. Information and counselling to reduce the risk of sexual transmission HIV testing and counselling Involve male partners in maternal, newborn and child health and family planning Increase awareness of the risk of vertical transmission Raise awareness that pregnant and postpartum women are at increased risk of HIV infection and that male partners are responsible for practicing safer sex Promote provider-initiated testing and counselling Include counselling on PMTCT and family planning in HIV counselling Support couple counselling, partner testing and safe and voluntary disclosure Promoting male and female condoms Promote condom use including during pregnancy and breastfeeding Offer guidance on how to negotiate condom use with partners Increase the availability of a full range of contraception within family planning, including condoms Family planning Promote provider-initiated HIV testing and counselling in family planning services, linked with counselling on reproductive choices and awareness of PMTCT Provide family planning counselling and contraceptives through HIV care and treatment and voluntary counselling and testing, antenatal care and postpartum services Managing sexually transmitted infections Gender-based violence Intensify antenatal screening and treatment of sexually transmitted infections, including syphilis Target high-risk groups with prevention and treatment services for sexually transmitted infections Provide comprehensive management and support for victims of gender-based violence Involve men in reducing gender-based violence 32 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Blood safety Provide iron and folate supplementation, malaria prophylaxis and deworming as appropriate to reduce the need for delivery-related blood transfusions Manage labour as appropriate to reduce the need for delivery-related blood transfusions Ensure safe blood supply Promote and implement universal precautions HIV-related stigma and discrimination Address health provider stigma and discrimination of people living with HIV and vulnerable groups Respect clients rights to confi dentiality, privacy, informed consent, decision-making and equitable care regardless of HIV status Annex 5. Key resources Press releases and calls to action Call to Action: Towards an HIV-free and AIDS-free generation. Prevention of Mother to Child Transmission (PMTCT) High Level Global Partners Forum, Abuja, Nigeria, December 3, 2005. Geneva, World Health Organization, 2005 (http://www.who.int/hiv/mtct/pmtct_calltoaction.pdf, accessed 13 June 2007). Glion Call to Action on Family Planning and HIV/AIDS in Women and Children, 3 5 May 2004. Geneva, World Health Organization and New York, United Nations Population Fund, 2004 (http://www.who.int/reproductive-health/stis/ linking.html, accessed 13 June 2007). New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health. New York, United Nations Population Fund, 2004 (http://www.unfpa.org/publications/detail.cfm?id=195, accessed 13 June 2007). Care for women living with HIV Standards for maternal and neonatal care. Geneva, World Health Organization, 2006 (http://www.who.int/making_ pregnancy_safer/publications/standards/en/index.html, accessed 13 June 2007). A set of user-friendly leafl ets that present WHO key recommendations on the delivery of maternal and neonatal care in health facilities, starting from the fi rst level of care. Chronic HIV care with ARV therapy and prevention: Integrated Management of Adolescent and Adult Illness (IMAI), Integrated Management of Childhood Illness (IMCI) interim guidelines for health workers at health centre or district hospital outpatient clinic. Geneva, World Health Organization, 2007 (http://www.who.int/3by5/publications/documents/ imai/en/index.html, accessed 13 June 2007). WHO and United Nations Population Fund. Sexual and reproductive health of women living with HIV/AIDS: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings. Geneva, World Health Organization, 2006 (http://www.who.int/hiv/pub/guidelines/sexualreproductivehealth.pdf, accessed 13 June 2007). WHO, UNFPA, UNAIDS and International Planned Parenthood Federation. Sexual and reproductive health & HIV/ AIDS: a framework for priority linkages. Geneva, World Health Organization, 2005 (http://www.who.int/reproductivehealth/stis/framework.html, accessed 13 June 2007). Meeting the sexual and reproductive health needs of people living with HIV. New York, Guttmacher Institute and Geneva, UNAIDS, 2006 (In Brief: 2006 Series, No. 6; http://www.guttmacher.org/pubs/ib_hiv.html, accessed 13 June 2006). 33

Prevention of mother-to-child transmission Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access. Recommendations for a public health approach. Geneva, World Health Organization, 2006 (http://www.who.int/hiv/ pub/guidelines/pmtctguidelines2.pdf, accessed 13 June 2007). Strategic approaches to the prevention of HIV infection in infants: report of a WHO meeting, Morges, Switzerland, 20 22 March 2002. Geneva, World Health Organization, 2003 (http://www.who.int/hiv/pub/mtct/pub35/en, accessed 13 June 2007). Strategic framework for the prevention of HIV infection in infants in Europe. Copenhagen, WHO Regional Offi ce for Europe, 2004 (http://www.who.int/hiv/mtct/pmtcteuro.pdf, accessed 13 June 2007). Glion Consultation on Strengthening the Linkages between Reproductive Health and HIV/AIDS: Family Planning and HIV/AIDS in Women and Children 25 May 2006. Geneva, World Health Organization, 2006 (http://www.who.int/hiv/ pub/advocacymaterials/glionconsultationsummary_df.pdf, accessed 13 June 2007). Infant feeding and HIV Technical Consultation Consensus Statement, 2006, World Health Organization, Geneva, WHO, for the Inter-Agency Task Team, HIV and Infant Feeding (http://www.who.int/child-adolescent-health/new_publications/nutrition/ consensus_statement.pdf, accessed 13 June 2007). HIV and infant feeding: framework for priority action. Geneva, World Health Organization, 2003 (http://www.who. int/nutrition/publications/infantfeeding/en/index.html, accessed 13 June 2007). HIV and infant feeding: guidelines for decision-makers. Geneva, World Health Organization, 2003(http://www.who. int/nutrition/publications/infantfeeding/en/index.html, accessed 13 June 2007). HIV and infant feeding: a guide for health-care managers and supervisors. Geneva, World Health Organization, 2003(http://www.who.int/nutrition/publications/infantfeeding/en/index.html, accessed 13 June 2007). What are the options? Using formative research to adapt global recommendations on HIV and infant feeding to the local context. Geneva, World Health Organization, 2003 (http://www.who.int/child-adolescent-health/new_ Publications/NUTRITION/ISBN_92_4_159136_6.pdf, accessed 13 June 2007). Other guides available online at: http://www.who.int/child-adolescent-health/publications/nutrition/hivc.htm, accessed 13 June 2007). HIV testing and counselling Guidelines for use in HIV testing and counselling services in resource-constrained settings. Geneva, World Health Organization, 2004 (http://www.who.int/hiv/pub/vct/en/rapidhivtestsen.pdf, accessed 13 June 2007). Testing and counselling for prevention of mother-to-child transmission of HIV (TC for PMTCT): support tools [web site]. Women, Children and HIV, 2007 (http://www.womenchildrenhiv.org/wchiv?page=vc-10-00, accessed 13 June 2007). UNAIDS/WHO policy statement on HIV testing. Geneva, UNAIDS and World Health Organization, 2004 (http://www. who.int/entity/hiv/pub/vct/en/hivtestingpolicy04.pdf, accessed 13 June 2007). Increasing access to HIV testing and counselling: report of a WHO consultation, 19 21 November 2002, Geneva, Switzerland. Geneva, World Health Organization, 2003 (http://www.who.int/hiv/pub/vct/pub36/en, accessed 13 June 2007). The right to know: new approaches to HIV testing and counselling. Geneva, World Health Organization, 2003 (http:// www.who.int/hiv/pub/vct/pub34/en, accessed 13 June 2007). Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Morbidity and Mortality Weekly Report Recommendations and Reports, 2006, 55:RR-14 (http://www.cdc.gov/hiv/ topics/testing/resources/reports/pdf/rr5514.pdf, accessed 13 June 2007). 34 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

Integrating HIV voluntary counselling and testing services into reproductive health settings. Stepwise guidelines for programme planners, managers and service providers. Delhi, International Planned Parenthood Federation South Asia Regional Offi ce and New York, UNFPA, 2004 (http://www.unfpa.org/upload/lib_pub_fi le/245_fi lename_hiv_ publication.pdf, accessed 13 June 2007). Guidance on provider-initiated HIV testing and counselling in health facilities. Geneva, World Health Organization, 2007 (http://www.who.int/mediacentre/news/releases/2007/pr24/en/index.html, accessed 13 June 2007). Target setting and monitoring and evaluation National AIDS programmes: a guide to monitoring and evaluating HIV/AIDS care and support. Geneva, World Health Organization, 2004 (http://www.who.int/hiv/pub/epidemiology/pubnapcs/en, accessed 13 June 2007). UNAIDS and WHO. National guide to monitoring and evaluation programmes for the prevention of HIV in infants and young children. Geneva, World Health Organization, 2004 (http://www.who.int/hiv/pub/prev_care/youngchildren/ en, accessed 13 June 2007). An updated version will be available in 2007. Forthcoming publications being developed by WHO and UNAIDS Technical guidance to set national targets for antiretroviral therapy Technical guidance to set national targets for PMTCT National indicators for monitoring and evaluation of testing and counselling programmes: updated list of indicators for comprehensive PMTCT monitoring and evaluation General documents containing specifi c information on women Follow up on the United Nations General Assembly Special Session on HIV/AIDS. Work of WHO. Progress report July 2002. Geneva, World Health Organization, 2002 (http://www.who.int/hiv/pub/advocacy/pubadvocacy2/en, accessed 13 June 2007). World AIDS Campaign, Live and Let Live, Strategy background note. Geneva, UNAIDS, 2002 (http://www.etharc. org/aidscampaign/publications/wac2004.pdf, accessed 13 June 2007). Practical guidelines for intensifying HIV prevention: towards universal access. Geneva, UNAIDS, 2007 (http://data.unaids. org/pub/manual/2007/20070306_prevention_guidelines_towards_universal_access_en.pdf, accessed 13 June 2007). Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach. 2003 revision. Geneva, World Health Organization, 2003 (http://www.who.int/3by5/publications/documents/arv_ guidelines/en, accessed 13 June 2007). Human capacity-building plan for scaling up HIV/AIDS treatment. Geneva, World Health Organization, 2004 (http:// www.who.int/3by5/publications/documents/capacity_building/en, accessed 13 June 2007). Partnership work: the health service community interface for the prevention, care and treatment of HIV/AIDS report of a WHO consultation, 5 6 December 2002, Geneva, Switzerland. Geneva, World Health Organization, 2003 (http://www.who.int/hiv/pub/prev_care/hivpub43/en, accessed 13 June 2007). Positive prevention: prevention strategies for people living with HIV/AIDS. Brighton, International HIV/AIDS Alliance, 2003 (http://www.aidsalliance.org/sw9438.asp, accessed 13 June 2007). Global HIV Prevention Working Group. HIV prevention in the era of expanded treatment access. Menlo Park CA, Kaiser Family Foundation, 2004 (http://www.kff.org/hivaids/hiv061004pkg.cfm, accessed 13 June 2007). 35

36 GUIDANCE ON GLOBAL SCALE-UP OF THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV

For more information, contact: World Health Organization Department of HIV/AIDS Avenue Appia 20 1211 Geneva 27 Switzerland ISBN 978 92 4 159601 5 E-mail: hiv-aids@who.int www.who.int/hiv